Closing to EMS (ALS) Ambulances "ED Sat"(uration)
- Joint decision by the AED charge nurse and AED attending
- Consider carefully as it results in longer transport times for potentially critically ill patients
- Indicators to consider:
- NEDOCS>140 (must be done hourly while on diversion status) and Hospital Surge level
- EMS closure criteria
- Surrounding hospital status
- All ED rooms are full (Peds=18, AED=34 [Tr 1-5, AED 2-23, RME 12-20]) and 30% or greater of the ED patients are ESI1, ESI2, or admit boarders
- If group decision is to close, proceed with the 1 hour ED closure; must reevaluate the department before going on ED ALS diversion again
- Closure to ED saturation should always be accompanied by closure to interfacility, ED to ED, and other transfers through the Medical Alert Center (MAC). All MAC closures are discussed with the Patient Flow Facilitator (PFF) or Administrative Officer of the Day (AOD).
- Other potential reasons for ambulance diversion:
- CT: based on the availability of alternate scanners; AED Attending will notify the ED Overall Charge for Reddinet entry
- Trauma: joint decision by Trauma and ED Attendings; based on equipment issues, OR unavailability, primary and backup trauma team encumbrance
- Peds: PED Attending contacts ED Overall Charge RN to close via Reddinet; PICU beds have no influence on PED diversion status
- STEMI: Joint decision amongst Interventional Cardiologist, AED Attending, House Supervisor, and ED Overall Charge Nurse; due to cath lab team encumbrance, mechanical failures, or internal disaster; automatically re-open after 3 hours unless further diversion is deemed necessary
- Internal Disaster (see https://www.wikem.org/wiki/Harbor:Disaster_plan)
- Helipad: due to unsafe landing conditions, damage to the helipad, current helicopter on the pad, deployment of the decon trailers for a large Hazmat incident; MAC must immediately be notified of closure
There are three levels of surge. The surge level is determined by meeting the "Resource Utilization Indicators" (see below). When a surge level is met, the patient flow facilitator, in consultation with the ED attending, will enact the surge plan. Alerts go out to all hospital departments. If you think criteria have been met to activate the Surge Plan - contact the Patient Flow Facilitator at 29721, x3434, or pager x0939.
What Happens at Different Surge Levels
- Level 1
- Ambulance Diversion (Diversion is for ALS only, never BLS)
- Four RME Rooms should be converted to Fast Track if not already done
- Assign residents as available to staff the extra Fast Track rooms
- UR Nurse works with Hospitalist and Admitting Residents to identify 2.76 Transfers (Hospitalist and Nurse Analysts look for patients to transfer that County will find special funding for)
- Charge nurse facilitates full staffing of Gold Unit by reallocating staff as available
- PFF communicates to Nurse Managers to get timely discharge/transfer orders from inpatient teams
- Level 2
- Above and:
- When beds are available upstairs, 4 OBS/CORE patients each hour are admitted and moved to inpatient beds. Hospitalist or CORE Cardiologist writes orders.
- CMO or designee determines need to cancel scheduled admissions, elective surgeries; requests department chairs to provide list of pending downgrades and discharges
- Level 3
- Above and:
- CMO or designee makes determination to go on Diversion to Trauma
- When beds are available upstairs, 6 OBS/CORE patients each hour are admitted and moved to inpatient beds. Hospitalist or CORE Cardiologist writes orders.
- AOD consult hospital leaders if need to open command center.
(1)There are multiple additional actions taken upstairs that are listed in the Surge Capacity Plan Policy (Hosp. Policy No. 337)
Resource Utilization Indicators (Need any 3)
- Surge Criteria Pilot - 7/10/19: ED census for surge criteria includes R5, R6, R7, & R12; Available med/surg OR ICU/PCU
(Dr. Peterson, Dr. Stein, Joy Lagrone, Mark Redulla [pt flow])
- Hospital LEAN initiative to avoid overcrowding (6/2019)
- Floor RN and Charge RN's evaluate patients daily for potential downgrades and directly contact the Attending
- Level 1
- NEDOCS >140
- > 50 Patients in Triage/Waiting Room (WR+R5+R6+R7+R12)
- > 11 OBS/CORE/Boarders in AED
- Inpatient census > 320
- Low inpatient bed count (<16 Ward OR <5 ICU/PCU beds)
- Based on current conditions, not beds that will be coming (will go off surge when conditions are no longer met)
- Ward should include unstaffed ward beds as they can be utilized in surge conditions per CEO
- Level 2
- NEDOCS >180
- > 50 Patients in Triage/Waiting Room (not including RME/tasking/internal WR like R5,R6,or R12)
- > 14 OBS/CORE/Boarders in AED
- Inpatient census > 330
- Lower inpatient bed count (EITHER <11 Ward AND <3 ICU/PCU beds OR No "Bump Bed" for Trauma or STEMI)
- 4 or more patients in the Recovery Room (PAR) awaiting ICU/PCU/SDU
- Level 3
- NEDOCS 200
- > 75 Patients in Triage/Waiting Room (not including RME/tasking/internal WR like R5,R6,or R12)
- > 17 OBS/CORE/Boarders in AED
- No available gurneys, chairs or monitors for new patients in ED
- Inpatient census > 345
- Low inpatient bed count (<5 ward OR 0 ICU/PCU beds with no "Bumps")
- 5 or more patients in the Recovery Room (PAR) awaiting ICU/PCU/SDU
(Hosp Policy 337)
Adult ED Attending Standard Work During Severe ED Overcrowding
- 1. Ensure that the MICN / Charge RN has updated the NEDOCS score. (Click on the colored bar to see when the NEDOCS score was last updated - should be updated every 2-3 hours)
- 2. If surge criteria met (see above), call Patient Flow Facilitator to check if surge plan has been initiated.
- 3. If you have ward beds and ED is impacted by Observation and Boarders - admit stable patients to the ward rather than placing them on Observation. See "OBSERVATION SURGE PLAN" (EXCEPTION: Placement patients - always initially place on Observation.)
- 4. Consider using the RME Fast Track rooms and/or Pediatric ED rooms to see patients who don't need to stay in a bed.
- 3. If time allows, go through patient charts on the admissions track and contact admitting inpatient teams of patients that might be downgradable.
(Director OPS, 3/22/18)
Observation Surge Plan
Whenever the number of OBS/CORE patients that overflow in the AED due to lack of GOLD Unit available beds equals or exceeds 5 patients AND there are inpatient beds available at the appropriate level of care:
- 1. Emergency Physicians will ADMIT any additional patients that are empanelled to the DHS network* to an inpatient bed rather than place the patient on Observation.
- 2. The Observation hospitalist will ADMIT any patients already on observation that are in DHS network*, giving priority to WARD level patients, followed by TELEMETRY level patients for this activity.
- 3. These two activities will only continue until we reduce the number of OBS/CORE patients in AED beds down to 5, after filling up all available GOLD beds.
EXCEPTION: Regardless of empanelment - patients perceived to have a high likelihood of needing placement will ALWAYS be placed/kept on Observation.
EMPANELLED TO DHS NETWORK = Provider name in the Empanelled Provider area of the Banner Bar in Cerner OR an insurance type that is listed as "DHS"
Peterson 8/15/ 18
- Harbor ED Policy 20.4, LA County EMS policies 503, 506, & 513